Looked-after children and young people

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1 Looked-after children and young people Issued: October 2010 last modified: April 2013 NICE public health guidance 28 guidance.nice.org.uk/ph28 NICE has accredited the process used by the Centre for Public Health Excellence at NICE to produce guidance. Accreditation is valid for 5 years from January 2010 and applies to guidance produced since April 2009 using the processes described in NICE's 'Methods for the development of NICE public health guidance' (2009). More information on accreditation can be viewed at accreditation NICE 2010

2 Contents Scope and purpose of this guidance... 8 What is this guidance about?... 8 Who is this guidance for?... 9 Changes to government policy from May What is the status of this guidance? How was this guidance developed? What evidence was the guidance based on? Foreword Principles and values Recommendations Influences on the quality of life of looked-after children and young people Strategic leadership, planning and commissioning Audit and inspection Care planning, placements and case review Professional collaboration Dedicated services to promote the mental health and emotional wellbeing of children and young people in care Placements for children and young people residential care, foster care and care by family and friends Sibling placements and contact Supporting babies and young children Health assessments, records and information Personal quality of life Diversity Supporting foster and residential care Care provided by family and friends Improving education for looked-after children and young people NICE All rights reserved. Last modified April 2013 Page 2 of 164

3 Preparing for independence Training for professionals Context Experiences of looked-after children and young people in England National policy and guidance Considerations Needs of looked-after children and young people Quality of care and placement stability Audit and inspection Residential and foster care, and care provided by family and friends Siblings Diversity Health assessments, records and information Dedicated services to promote mental health and wellbeing Supporting babies and young children Improving educational outcomes Reaching adulthood and preparing for independence Safeguarding Evidence Cost-effectiveness evidence Implementation Recommendations for research Recommendations Research questions Updating the recommendations Related SCIE and NICE publications and guidance NICE All rights reserved. Last modified April 2013 Page 3 of 164

6 Guidance development Key questions Effectiveness reviews Other reviews Economic analysis Fieldwork Consultation with looked-after young people and care leavers How the PDG formulated the recommendations Appendix C: The evidence Strategic leadership, planning and commissioning Audit and inspection Care planning, placements and case review Professional collaboration Dedicated services to promote the mental health and emotional wellbeing of children and young people in care Placements for children and young people residential care, foster care and care by family and friends Sibling placements and contact Supporting babies and young children Health assessments, records and information Personal quality of life Diversity Supporting foster and residential care Care provided by family and friends Improving education for looked-after children and young people Preparing for independence Evidence statements Expert testimony NICE All rights reserved. Last modified April 2013 Page 6 of 164

7 Cost-effectiveness evidence Fieldwork findings Consultation with looked-after young people and care leavers Appendix D: Supporting documents About this guidance Changes after publication NICE All rights reserved. Last modified April 2013 Page 7 of 164

8 Scope and purpose of this guidance This is joint guidance produced by the National Institute for Health and Clinical Excellence (NICE) and the Social Care Institute for Excellence (SCIE). It was developed using the NICE public health programme process. It has used a mixture of SCIE and NICE methods see appendix B for details. What is this guidance about? This guidance aims to improve quality of life (that is, the physical health, and social, educational and emotional wellbeing) of looked-after children and young people. The focus is on ensuring that organisations, professionals and carers work together to deliver high quality care, stable placements and nurturing relationships for looked-after children and young people. The recommendations set out how agencies and services in a complex, multi-agency environment can improve the quality of life for looked-after children and young people through more effective collaboration that places them at the heart of all decision making. The recommendations cover local strategy and commissioning, multi-agency working, care planning and placements, and timely access to appropriate health and mental health services. This guidance does not provide detailed information on health promotion, or cover treatments for specific illnesses and conditions. Section 7 has details of National Institute for Health and Clinical Excellence (NICE) and Social Care Institute for Excellence (SCIE) guidance that is particularly relevant to looked-after children and young people and their families or carers. The term 'looked-after children and young people' is used in this guidance to mean those looked after by the State where the Children Act 1989 applies, including those who are subject to a care order or temporarily classed as looked after on a planned basis for short breaks or respite care. This guidance covers children and young people from birth to age 25, wherever they are looked after in residential care, foster care, young offender or other secure institutions or boarding school, or with birth parents, other family or carers, and including placements out of the area. When the term 'carers' is used in this document, unless explicitly stated otherwise, it means all NICE All rights reserved. Last modified April 2013 Page 8 of 164

9 those involved in the direct day-to-day care of children and young people including foster residential and carers who are family or friends. For further details of what is included and excluded from this guidance, see the scope. Who is this guidance for? The guidance is for all those who have a direct or indirect role in, and responsibility for, promoting the quality of life of looked-after children and young people. This includes directors of children's services, commissioners and providers of health (including mental health) and social care services, directors of public health, social workers and social work managers, carers (including foster carers), local authorities, schools, voluntary and independent agencies, organisations responsible for the training and development of professionals, universities and colleges, regulatory bodies and inspectorates. The guidance may also be of interest to lookedafter children and young people, their families, prospective adopters and other members of the public. Changes to government policy from May 2010 Changes to government policy have major implications for this guidance, which are as follows. At the time of writing (September 2010), the duty on schools to cooperate with children's trusts is likely to be removed, as is the requirement for local authorities to set up children's trust boards, and for those boards to produce a children and young people's plan. Government policy is to support effective local partnerships, but to allow local innovation and solutions to emerge. Importantly for this guidance, the 'duty to cooperate' will remain but the list of statutory partners will be reviewed. Announcements have been made that affect the current regulation arrangements. The Audit Commission is to be abolished and the Comprehensive Area Assessment audit of local authorities will cease. The Office for Standards in Education, Children's Services and Skills (Ofsted) and the Care Quality Commission (CQC) seem likely to remain the inspectorates of services for children's social care and health, and there will be an expansion of the economic regulator (currently Monitor) to develop with CQC 'licensing' arrangements for the NHS. NICE All rights reserved. Last modified April 2013 Page 9 of 164

10 Changes to NHS commissioning have been announced. GP commissioning consortia are likely to be fully operational in 2013/14, gradually taking over responsibility from primary care trusts (PCTs). PCTs are likely to be abolished from April Structures and statutory guidance are likely to change as a result of proposed government policies but the tasks and actions set out in the recommendations in this guidance remain valid. This guidance takes account of proposed policy changes by using generic terms alongside current arrangements to reflect possible structural changes. For example, the term 'commissioners of health services' has been used in place of 'PCT commissioners'. What is the status of this guidance? The Department of Health (DH) asked the National Institute for Health and Clinical Excellence (NICE) and the Social Care Institute for Excellence (SCIE) to produce this joint guidance. Although not statutory, this guidance can help children's services in social care and health meet their obligations to improve the health and wellbeing of looked-after children and young people (for further details, see section 4, 'Implementation'). The guidance should be implemented alongside other guidance and regulations (for more details see sections 2 and 9), including: 'Statutory guidance on promoting the health and well-being of looked after children' (Department for Children, Schools and Families and DH 2009) 'The Children Act 1989 guidance and regulations volume 2: care planning, placement and case review' (HM Government 2010). How was this guidance developed? The recommendations in this guidance are based on the best available evidence. They were developed by a Programme Development Group (PDG), which included people working in social care, health and education as well as young people with experience of being looked after. Members of the PDG are listed in appendix A. The guidance was developed using the NICE public health programme process. It has used a mixture of SCIE and NICE methods see appendix B for details. Supporting documents used to NICE All rights reserved. Last modified April 2013 Page 10 of 164

11 prepare this document are listed in appendix E. More details of the evidence on which this guidance is based, and NICE's processes for developing public health guidance, are on the NICE website. What evidence was the guidance based on? The evidence that the PDG considered included research reviews, a practice survey, a consultation with young people who are or have been in care, fieldwork with practitioners and the testimony of expert witnesses. This evidence demonstrated that the health and wellbeing of looked-after children and young people is affected by nearly all aspects of their lives and care. The PDG therefore examined the wider looked-after children's system and adopted a broad definition of health and wellbeing. Further detail on the evidence is given in section 3 ( ) and appendices B and C. The PDG recognised that some groups for example, disabled children and young people have specific needs, but it has not made recommendations about all of these. In some cases the evidence was insufficient and the PDG has made some recommendations for future research. Taking account of the views of children and young people During the consultation, children (where appropriate) and young people in care were asked what they thought about the recommendations that would directly affect them. For example, some said that they felt adults responsible for their care could be more honest with them, especially about decisions they can have some control over and those that are out of their hands. Their opinions were reported back to the PDG, some of which resulted in changes to the recommendations. NICE All rights reserved. Last modified April 2013 Page 11 of 164

12 Foreword The focus of this guidance promoting the quality of life for looked-after children and young people depends on how well organisations, professionals and carers work together to ensure looked-after children and young people experience high quality care, stable placements and nurturing relationships that reinforce a sense of belonging. The relationship between a child or young person, their carer and professionals involved in their lives and the continuity of that relationship has been central to the discussions of the Programme Development Group (PDG) throughout the development of this guidance. Much of the evidence that the PDG heard identified the importance of secure attachments and establishing a sense of permanence. The child's need to be loved and nurtured is fundamental to achieving long-term physical, mental and emotional wellbeing. The PDG heard that stable education built on high aspirations is essential to promoting the quality of life for looked-after children and young people. It also heard that their transition to adulthood can often be traumatic. Without access to services to support this transition young people can end up unemployed, homeless or in custody, experiencing a downward spiral of rejection. A disproportionate number of children and young people in care are from black and minority ethnic backgrounds and have particular needs. There are also other groups of looked-after children and young people, such as unaccompanied asylum seekers or those who are gay or lesbian, who have particular needs. Services should be sufficiently diverse and sensitive to meet the needs of these groups. Nationally, the quality of services for looked-after children and young people is uneven. Despite guidance and regulation, compliance is variable and questions about leadership have been raised. The PDG heard evidence that strongly suggests that effective leadership is the ability to create an organisational culture with a strong learning capacity. The ability to acquire, assimilate and apply knowledge and take seriously the need to learn from mistakes is critical. This NICE/SCIE guidance reinforces statutory guidance and national minimum standards without repeating the detail; it highlights key messages and fills some gaps. The guidance is aimed at a broad, cross-agency professional audience and the recommendations should act as levers for good practice and service improvement. NICE All rights reserved. Last modified April 2013 Page 12 of 164

13 The PDG took the view that when difficult decisions are made about budgets and resources, looked-after children and young people should be a priority, as one of the most vulnerable and disadvantaged groups in our society. Our aspirations should be high and not be compromised. Dennis Simpson Programme Development Group Chair NICE All rights reserved. Last modified April 2013 Page 13 of 164

14 Principles and values The recommendations in this guidance are supported by the following principles [1] : Put the voices of children, young people and their families at the heart of service design and delivery. Deliver services that are tailored to the individual and diverse needs of children and young people by ensuring effective joint commissioning and integrated professional working. Develop services that address health and wellbeing and promote high-quality care. Encourage warm and caring relationships between child and carer that nurture attachment and create a sense of belonging so that the child or young person feels safe, valued and protected. Help children and young people to develop a strong sense of personal identity and maintain the cultural and religious beliefs they choose. Ensure young people are prepared for and supported in their transition to adulthood. Support the child or young person to participate in the wider network of peer, school and community activities to help build resilience and a sense of belonging. Ensure children and young people have a stable experience of education that encourages high aspiration and supports them in achieving their potential. [1] These were developed by the Programme Development Group based on the principles in the 'Statutory guidance on promoting the health and well-being of looked after children' (Department for Children, Schools and Families and DH 2009), the six entitlements of the National Children's Bureau 'National Healthy Care Standard', and discussion of a quality of care index developed by David Berridge and colleagues. For details of the index, see Stein M (2009) Quality matters in children's services: messages from research. London: Jessica Kingsley Publishers. NICE All rights reserved. Last modified April 2013 Page 14 of 164

15 1 Recommendations There have been changes in recommendations 3, 5, 12, 36 and 38. See Changes after publication for details. This is NICE and SCIE's formal guidance on improving the physical and emotional health and wellbeing of looked-after children and young people. When writing the recommendations, the Programme Development Group (PDG) (see appendix A) considered the evidence of effectiveness (including cost effectiveness), commissioned reports, expert testimony, fieldwork data, a consultation with children and young people, and comments from stakeholders. Full details are available from the NICE website. The evidence statements underpinning the recommendations are listed in appendix C. The evidence reviews, commissioned reports, supporting evidence statements and economic analysis are available online. Influences on the quality of life of looked-after children and young people This diagram is in the full guidance document. Note that health and social care services include dedicated services to promote the mental health and emotional wellbeing of looked-after children and young people, and to support young people in the transition to independence. Services should be designed to address the needs of children and young people with particular needs, including those from black and minority ethnic backgrounds, unaccompanied asylum seekers and those with disabilities. The quick reference guide to this guidance gives an overview of the topics covered, and will help different professional groups identify which recommendations are relevant for them. Strategic leadership, planning and commissioning Evidence indicates that high-performing local authorities are those with strong leaders who have an aspirational vision of effective corporate parenting for all looked-after children and young NICE All rights reserved. Last modified April 2013 Page 15 of 164

16 people. These authorities embed partnership and multi-agency working at the heart of the planning process and ensure that children and young people are fully engaged in the design and delivery of services. Recommendation 1 Prioritise the needs of looked-after children and young people Who should take action? Directors of children's services. Directors of public health. Senior staff with responsibility for commissioning and providing health services. What action should they take? Create strong leadership and strategic partnerships to develop a vision and a corporate parenting strategy that: focuses on effective partnership and multi-agency working addresses health and educational inequalities for looked-after children and young people. Ensure that local strategic plans adhere to national guidance, primarily 'Statutory guidance on promoting the health and well-being of looked after children' [2]. Ensure the joint strategic needs assessment process [3] is a central component in assessing the needs of looked-after children and young people. Ensure local plans and strategies for children and young people's health and wellbeing fully reflect the needs of looked-after children and young people, and care leavers, and set out how these needs will be met. They should describe how to: meet the changing needs of looked-after populations and provide high-quality care provide services that meet the emotional health and wellbeing needs of children and their carers, including child and adolescent mental health services (CAMHS), core NICE All rights reserved. Last modified April 2013 Page 16 of 164

17 health services (for example, immunisation) and enhanced services (for example, paediatrics) promote healthy lifestyles provide access to extra-curricular activities improve the stability of placements and education. Ensure senior managers in partner agencies provide strong, visible leadership to raise aspirations and attainment, and promote joint working to meet the needs of looked-after children and young people. Ensure effective corporate parenting by complying with guidance on the role of lead members for children's services and directors of children's services [4] in helping looked-after children and young people improve their aspirations and outcomes. Ensure services are developed taking account of the views of looked-after children and young people (see recommendation 24). These views should be channelled through the corporate parenting board or children-in-care council. Provide an annual report to the children-in-care council, the local authority overview and scrutiny committee, the director of public health, the NHS commissioner and the leader of the council. This report should cover the effectiveness of services for looked-after children and young people when evaluated against local plans for health and wellbeing, the local pledge to children in care, national indicators and local targets. Build communication networks with key partner organisations and publish, publicise and update regularly a local map that identifies all agencies that are involved with looked-after children and young people. Publish and update regularly a directory of resources for looked-after children and young people to aid social workers, and a resource guide for looked-after children and young people and care leavers. Ensure local authorities reflect in their yearly 'pledge' to looked-after children and young people the needs and challenges raised by children-in-care councils about improving services to achieve better outcomes. NICE All rights reserved. Last modified April 2013 Page 17 of 164

18 Recommendation 2 Commission services for looked-after children and young people Who should take action? Commissioners of health services and local authority children's services. What action should they take? Commission services that enhance the quality of life of the child or young person by promoting and supporting their relationships with others. Ensure that service commissioning for looked-after children and young people is informed by: the views of children and young people (see recommendation 24) national evidence, guidance and performance data the local corporate parenting strategy local knowledge and experts (for example, the director of public health) local audits the joint strategic needs assessment local plans and strategies for children and young people's health and wellbeing. Commission services dedicated to looked-after children and young people that are integrated, preferably on the same site, and have expert resources to address physical and emotional health needs. These services should have links with universal services, be friendly, accessible and non-stigmatising [5] and should include: health promotion (see recommendations 37 and 46) early identification and prevention of physical and emotional health problems (see recommendations 8 11 and 20 23) access to specialist services, including child and adolescent mental health services (see recommendations 8 11) NICE All rights reserved. Last modified April 2013 Page 18 of 164

19 access to professional advice for the looked-after children and young people's care team (see recommendation 6). Encourage authorities to work together in local partnerships when commissioning services to offer greater choice and quality of services. Audit and inspection Evidence suggests that a robust audit and inspection framework ensures that looked-after children and young people continue to be strategic priorities for local authorities, the NHS and their key partners. Recommendation 3 Regulate services Who should take action? Regulators and inspectors (including the Care Quality Commission and Ofsted). What action should they take? Use the processes for auditing, monitoring and inspecting local authorities, providers of health services and key partners to ensure local partnerships (including children's services and their partners) provide services for looked-after children and young people (including those placed out of area) that: take account of their views (see recommendation 24) meet the full range of their needs (including needs relating to physical, social, educational and emotional health and wellbeing) promote and support healthy lifestyles deliver quality care, and placement and educational stability comply with relevant standards and statutory guidance. Assess local partnerships (including children's services and their partners) to: ensure the needs of looked-after children and young people are given the priority that statutory guidance dictates NICE All rights reserved. Last modified April 2013 Page 19 of 164

20 ensure mainstream budgets are pooled or aligned to meet those needs ensure effective joint commissioning of services is in place and show how costs are shared between agencies. Recommendation 4 Inspect services for care leavers Whose health and wellbeing will benefit? Looked-after young people preparing to leave or leaving care. Who should take action? Ofsted. Care Quality Commission. What action should they take? Adopt the standards developed by the National Leaving Care Advisory Service [6]. Extend the inspection care frameworks (under the Care Standards Act 2000) to services for care leavers aged 18 and older to ensure standards of service provision are adequate. Monitor the provision of health services and how well different services communicate with one another. Care planning, placements and case review Evidence indicates that effective care planning, led by social workers, promotes permanence and reduces the need for emergency placements and placement changes. Good care planning supports the quality of the relationship between the child or young person and carer by minimising disruption, increasing attachment and providing greater placement stability, which also helps promote a stable education. NICE All rights reserved. Last modified April 2013 Page 20 of 164

21 Recommendation 5 Implement care planning, placement and case review regulations and guidance Who should take action? Directors of children's services. What action should they take? Ensure all social workers and independent reviewing officers (IROs) refer to and implement the statutory guidance on care planning, placement and case review [7]. These documents set out the statutory duties of children's services, which include ensuring that social workers carry out their pivotal role of 'local corporate parent' with overall responsibility for the coordination and implementation of the care plan and healthcare plan (also see recommendations 26 34). Ensure the social worker's role is supported by: regular high-quality supervision with a particular focus on the management of the care plan and corrective action to ensure that interventions are acted on as agreed preventing 'drift' in the care system continuing professional development for social workers to better understand and manage the role of a local corporate parent. Implement in full the strengthened function of the independent reviewing officer as outlined in 'Putting care into practice: statutory guidance on care planning, placement and case review for looked after children [8] ' and the 'IRO handbook [8] '. Ensure the expanded and strengthened role of independent reviewing officers (see recommendation 52 on IRO training) is supported by high-quality supervision. Ensure that prompt and decisive action is taken when planning permanence for very young children and babies who come into care (see also recommendations 16 19), to safeguard and promote the wellbeing of the child. For example, where there is any uncertainty concerning reunification with birth parents, 'twin tracking' should be in place to ensure other permanence arrangements are available. NICE All rights reserved. Last modified April 2013 Page 21 of 164

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